As men age, testosterone levels gradually decline. And, low testosterone levels (clinically termed hypogonadism) lead to decreased well-being, increased risk of cardiovascular disease, loss of muscle, increased risk of Type 2 diabetes and other metabolic syndrome diseases, reduced sexual function, and bone loss.

Benefits of testosterone replacement therapy (TRT) are clearly established: improved sexual function, increase in lean muscle mass and strength, mood and cognitive function, with possible reduction in frailty and osteoporosis. However, recently some questions have arisen regarding the risk of heart attack and stroke in men receiving TRT.

The cardiovascular issues associated with TRT have been clarified by recent studies showing clearly that increased testosterone levels are associated with reduced mortality. Studies reporting increased risk have been flawed designs with inadequate baseline diagnosis and follow-up testing. An extensive review of the testosterone replacement therapy literature reveals that the majority of clinical studies show that properly administered testosterone replacement therapy, in which estradiol and dihydrotestosterone levels are also controlled, does not increase the risk of cardiovascular events. And, more good news: there is no evidence that TRT is associated with increased risk of prostate cancer or symptomatic benign prostatic hyperplasia.

Testosterone replacement therapy should be monitored, and when needed, an aromatase inhibitor such as anastrazole should be added to control estradiol levels that tend to increase with testosterone therapy; as well as an a 5α-reductase inhibitor, such as dutasteride or finasteride to control dihydrotestosterone (DHT) levels.

At the recommendation of the National Association of Boards of Pharmacy, we suggest that patients should always seek medical attention immediately if symptoms of a heart attack or stroke are present, such as:

• Chest pain
• Shortness of breath or trouble breathing
• Weakness in one part or one side of the body
• Slurred speech

Testosterone therapy is available in many forms, and transdermal preparations that are applied to the skin are quite popular. Creams are easy for the patient to use and many health care professionals and patients prefer daily administration of testosterone to long-lasting pellets and injections.

Another option is compounded troches, which offer these benefits:

• Decreased risk of cross contamination, i.e., men need not be concerned about others contacting the site of application, such as the arm or leg when a child or pet is held.
• Rapid buccal or sublingual absorption means the dose can reduced compared to that required for transdermal forms of testosterone.
• Patients can quickly achieve peak levels when desired.